Course Management of Prevalent Infections in Children Following a Disaster

Acute Respiratory Infections: The Patient with Cough or Difficult Breathing

All types of respiratory infections are more common among people living in overcrowded conditions in Low and middle income countries. Most cases of acute respiratory infections (ARI) are viral upper respiratory tract infections that need not be managed with antibiotics. But accurately identifying and then treating pneumonia is essential. Pneumonia remains a major cause of child mortality and morbidity. Approximately 155 million new episodes of clinical pneumonia occur in children under 5 years of age annually. It is estimated that 7%–13% of episodes are severe enough to be life-threatening and require hospitalization Studies have identified Streptococcus pneumoniae, Haemophilus influenzae, and respiratory syncytial virus (RSV) as the main pathogens associated with severe childhood pneumonia.

The IMCI strategy uses 4 key clinical signs to assess chil­dren with cough or difficult breathing:

• Respiratory rate (RR) distinguishes the presence or absence of pneumonia.
• Lower chest wall indrawing indicates more serious pneumonia.
• Stridor in a calm child indicates severe upper airway obstruction and the need for hospital admission.
• Wheezing indicates bronchiolitis or asthma

Respiratory rate

No single clinical sign has a better combination of sensitivity and specificity to detect pneumonia in children under 5 years than RR. Even auscultation by an expert is less sensitive as single sign. Cutoff rates for fast breathing (tachypnea) depend on the child’s age. Normal RR is higher in children aged 2 to 12 months than in children from 12 months to 5 years (Table 1).

The specificity of RR for detecting pneumonia depends on the prevalence of bacterial pneumonia among the population. In areas with high levels of viral pneumonia, RR has relatively modest specificity. Nevertheless, even if the use of RR leads to some over-treatment, this will still be small compared with the use of antibiotics among all children with an ARI, as frequently occurs. One minute RR timers are available when needed to obtain accurate rates.

Lower chest wall indrawing

Lower chest wall indrawing is when the lower chest wall goes in when the child breathes in. It is a useful marker of severe pneumonia. It is more specific than “intercostal indrawing,” when only the soft tissue between the ribs or above the clavicle goes in when the child breathes. Chest indrawing should only be considered present if it persists in a calm child. Agitation, a blocked nose, or breastfeeding can all cause temporary chest indrawing.

Stridor

Look and listen for stridor in a calm child, which indicates severe upper airway obstruction and the need for hospital admission. Stridor is a harsh noise made when the child inhales. Children who present with stridor when calm are at substantial risk of upper airway obstruction. Some children with mild croup manifest stridor only when they are crying or agitated.

Wheezing

Sometimes a wheezing noise is heard at exhalation. Wheezing is usually associated with asthma or viral bronchiolitis. With fast breathing, no distinction is made between children with bronchiolitis and those with pneumonia.

In some cases, especially when a child has wheezing at exhalation, the final decision on presence or absence of fast breathing can be made after a test with a rapid-acting bronchodilator (if available). Experience suggests that even where asthma rates are high, mortality from asthma is relatively uncommon.

Classification of children with cough or difficult breathing

Based on a combination of the aforementioned clinical signs, children presenting with cough or difficult breathing can be classified into 3 categories: those who require urgent referral for possible severe croup, or very severe disease, those with pneumonia who require antibiotics as outpatients, and those with a cold or asthma exacerbation who do not require antibiotic treatment (Box 3).

The group requiring referral for possible very severe disease includes children with any general danger sign, or stridor when calm. Children with very severe disease are more likely to have life-threatening invasive bacterial infections. IMCI guidelines changed when studies showed that oral antibiotic therapy is equivalent to parenteral or intravenous antibiotics for hospitalized cases of pneumonia without danger signs.

Give outpatient antibiotics to children with a fast RR for their age to treat bacterial pneumonia when they do not have additional danger or severe signs. Fast breathing, as defined by WHO, detects about 80% of children with pneumonia who need antibiotic treatment. Treatment based on this classification has been shown to reduce mortality.

Patients with cough and no signs suggesting pneumonia or severe disease do not require antibiotics. Such children may require a safe agent to relieve cough. A child with cough will normally improve in 1 to 2 weeks. However, a child with chronic cough (more than 30 days) needs to be further assessed (and, if needed, referred) to rule out tuberculosis, asthma, whooping cough, or another respiratory problem (Mulholland et al., 1992).

Antibiotics

First-line oral antibiotics for suspected pneumonia is amoxicillin. An alternative possibility is cotrimoxazole (trimethoprimsulfamethoxazole). When a child is vomiting and cannot take an oral antibiotic consider treating with an initial IM injection of procaine penicillin followed by a course of oral antibiotics. Hospitalized severe pneumonia cases are usually treated with a second or third generation cephalosporin such as IM ceftriaxone.